1

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report - PRACTICES

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Broom, A.

Antibiotic optimisation in

‘the bush’: Local know-how and core-periphery

relations

Hea

lth

Pla

ce

20

17

Au

stra

lia

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y Antimicrobial practice is deeply embedded in experiences of being on the geographical periphery,

and at the periphery of (established) knowledge. Health, place, and biographies intersect and shape how clinicians manage infections and perceive the problem

of resistance.

Strategies of ‘antibiotic optimisation’ must be embedded in an understanding of the importance and

complexity of the locale they aim to regulate.

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.he

alth

pla

ce.2

01

7.0

9.0

03

Broom, A.

The private life of medicine:

accounting for antibiotics in the

‘for-profit’ hospital setting

Soc

Theo

ry &

Hea

lth

20

18

Au

stra

lia

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

In private hospitals, the economic context and infection management intersect to produce institutional and

relational pressures, and an implicit set of obligations in the privatised environment. These revolve around

reputational and economic pressures for the private hospital as a business entity; external issues related to the funding of acceptable practices driven by private insurers; and, consumerist obligations to the patient.

Market-driven forces create a distinct set of obligations that could undermine the local and global antibiotic

optimisation agenda. Given the increasingly privatised landscape of healthcare, exploring the nexus of economics and practice will be vital in retaining

antibiotics for the future.

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7/s

41

2

85

-01

8-0

06

3-8

Broom, A.

Antimicrobial Resistance, Politics, and

Practice in India. Qu

al H

ealt

h

20

20

Ind

ia

Hu

man

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

Inte

rvie

w s

tud

y

The social dimensions of AMR in India cut across unregulated environs, multiple markets, competing

expert systems and unique, localized conditions. They are set against the background of socioeconomic

vulnerabilities. These situated accounts of practice offer considerable insight into the complex web of potential

economic, cultural, organizational, and political “factors” which may be fundamental to the production

and reproduction of practices complicit in the acceleration of AMR.

Our findings offer broader context to reframe resistance in India as multifactorial, enacted through cultural/local practices, and irreducible to singular problems of control or regulation

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04

97

32

32

0

91

90

88

2

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Broom, J.

The drivers of antimicrobial use

across institutions,

stakeholders and economic settings: a

paradigm shift is required for

effective optimization

J A

nti

mic

rob

Ch

emo

ther

20

19

Au

stra

lia

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

Social relationships and institutional structures have a strong influence on antimicrobial use. These include the influence of personal risk, hierarchies, inter- and intra-professional dynamics and sense of futility in making a

difference long term in relation to antimicrobial resistance. Influential institutional structures include patient population factors (including socioeconomic

factors, geographical isolation and local infection patterns), proximity and resource issues

Antimicrobial optimization has tended to emphasize individual ‘behaviour improvement’ in prescribing. A

paradigm shift is urgently needed to incorporate personal, interpersonal and institutional variables.

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3/j

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kz2

3

3

Buller, H.

Veterinary Diagnostic

Practice and the Use of Rapid

Tests in Antimicrobial

Stewardship on UK Livestock

Farms

Fro

nt

Vet

Sci

20

20

Un

ite

d K

ingd

om

An

imal

Inte

nsi

ve f

arm

ing

Inte

rvie

w s

tud

y

Diagnosis, as a practice, is both a scientific and a social process, lying at the very center of medical and

veterinary activity and professional legitimacy. Rapid or point-of-care tests are not seen by UK farm animal

veterinarians, at least at the current time, as the critical panacea for antimicrobial use reduction across all

production sectors

The growing availability of rapid and point-of-care tests effectively diversifies the range of diagnostic actors with consequences for the flow of diagnostic and disease information, rather than replacing them.

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9

/fve

ts.2

02

0.5

69

54

5

Charani, E.

The Differences in Antibiotic

Decision-making Between Acute

Surgical and Acute Medical

Teams: An Ethnographic

Study of Culture and Team Dynamics

Clin

Infe

ct D

is

20

18

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Eth

no

grap

hic

stu

dy

Different medical specialties have their own language, behaviors, social norms, and values. In medicine teams,

the legacy of infection diagnosis made in the emergency department determines antibiotic decision-

making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. This

results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use.

Colleagues with expertise in antibiotics should engage and communicate with surgeons in a way that

accommodates their working patterns and their preferred platform (phone, text messaging); Define a

dedicated clinical role for antibiotic stewardship within the surgical team who has responsibility for ensuring appropriate antibiotic management for their team’s

patients; Target stewardship interventions in the first 48 hours after admission to rationalize antibiotics

started; Have a clinical pharmacist as part of medical ward rounds will assist with appropriate antibiotic use.

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44

3

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Charani, E.

Investigating the cultural and contextual

determinants of antimicrobial stewardship programmes across low-,

middle- and high-income

countries—A qualitative study

PLo

S O

ne

20

19

Bu

rkin

a Fa

so, F

ran

ce, N

orw

ay,

Ind

ia, U

nit

ed K

ingd

om

Hu

man

Ho

spit

al

Eth

no

grap

hic

stu

dy Antimicrobial stewardship programmes were restricted

by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. The

surgical specialty was identified as most difficult to engage with in each country. At the macro level government and state infrastructures determine

antimicrobial stewardship programmes.

There needs to be promotion of interdisciplinary team work including pharmacists and nurses, (depending on the available healthcare workforce) including through

local leadership/ antimicrobial stewardship champions. Contextually driven programmes targeting the surgical

pathway in different resource settings need to be developed. Legislation and investment in resources to support local Antimicrobial stewardship programmes

are needed. However too much government involvement can disrupt such efforts and cause

redirection of limited resources.

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0.1

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1/j

ou

rnal

.po

ne.

02

09

84

7

Charani, E.

Antibiotic Stewardship-

Twenty Years in the Making.

An

tib

ioti

cs (

Bas

el)

20

19

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Rev

iew

Antibiotic decision-making is a social process dependent on cultural and contextual factors. Cultural

boundaries in healthcare and across specialties limit the involvement of allied healthcare professionals in

stewardship interventions. The cultural differences between specialties and healthcare professionals shape the shared knowledge within and across specialties in

the patient pathway, resulting in variation in care.

Bespoke stewardship interventions that account for contextual variation in practice are necessary. Globally,

resources remain a limiting factor antibiotic stewardship program implementation.

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0/a

nti

bi

oti

cs8

01

00

07

Charoenboon, N.

Translating antimicrobial

resistance: a case study of context

and consequences of antibiotic-related communication

in three northern Thai villages

Pal

grav

e C

om

mu

n

20

19

Thai

lan

d

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Cas

e st

ud

y

Participants aligned their antibiotic-related attitudes and behaviours with the activity’s recommendation,

However, fragmented local healthcare landscapes limited villagers’ ability to act on the activity but also

provided a market opportunity for informal antibiotics sales, and interactions with parallel yet misunderstood

public health campaigns created rumours and resistance.

Comprehensive mixed-method evaluations of future campaigns with mandatory two directional knowledge exchange components are needed. Popular overuse of

antibiotics may only be the symptom of a larger problem of precarious living conditions and lacking

social support, which could not be rectified with health policy interventions alone.

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19

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26

-9

4

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Chauhan, A.

The social biography of

antibiotic use in smallholder dairy

farms in India

An

tim

icro

b R

esis

t In

fect

Co

ntr

ol

20

19

Ind

ia

An

imal

Smal

lho

lder

s

Inte

rvie

w s

tud

y

Smallholding dairy farmers operated within very small margins of profits. The paucity of formal veterinary services at the community level, coupled with easy

availability of antibiotics and the need to ensure profits and minimise losses, promoted non-prescribed

antibiotic consumption. In the presence of weak veterinary care infrastructures with limited outreach activities, severe human resource limitations, poor

legislative and regulatory oversight, and limited knowledge and awareness of the role of antibiotics in consumers, it will be difficult to combat the issue of

emergent antibiotic resistance

Interventions such as community awareness programmes related to veterinary antibiotics,

establishing an effective drug distribution policy, imposing penalties on defaulters, and strengthening of veterinary human resources both in terms of quantity as well as competence is required to address the issue

adequately.

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0.1

18

6/s

13

75

6-0

18

-03

54

-

9

Chen, M.

Prescribing Antibiotics in

Rural China: The Influence of

Capital on Clinical Realities

Fro

nt.

So

cio

l.

20

20

Ch

ina

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y The demands of both practitioners’ and patients’ social, cultural, and economic forms of capital help to explain patterns of antibiotic prescribing. Official regulations

and institutional pressures to generate revenues, informants’ desire to maintain good relations with

patients coupled with their concerns for patient safety result in tensions between their professional knowledge

of “rational” antibiotic and their practices.

Cultural and economic forms of capital as particularly salient in this setting and thereby offer a valuable and

original perspective for better understanding the sociocultural factors impacting clinician antibiotic

prescribing practices.

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2

02

0.0

00

66

5

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Cooke, P.

What is 'antimicrobial

resistance'; and why should

anyone make films about it?

Using 'participatory

video' to advocate for

community-led change in public

health.

New

Cin

emas

20

20

Nep

al

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Cas

e st

ud

y

We examine the world-view presented in the films this project generated. We consider the complexity of the power relationships at work in these films, which, in

turn, allow us to reflect on the processes at work in in participatory film making and AMR awareness raising

activities.

Participatory video could be used as a tool for developing community-level solutions to AMR

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cin

_00

00

6_1

Davis, M.

Understanding media publics

and the antimicrobial

resistance crisis

Glo

b P

ub

lic H

ealt

h

20

17

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Rev

iew

We consider the challenge of communicating about antimicrobial resistance in light of ‘media publics’,

including: the tendency of health communications to cast experts and lay individuals in opposition; the

blaming of individuals who appear to ‘resist’ expert advice; the challenges presented by negative stories of

AMR and their circulation in public life, and; the problems of public trust tied to the construction and

mediation of expert knowledge on the effective management of antimicrobial resistance.

Public policy and communications that appreciate the complexities of biomedicalised social worlds can

enhance public communications on AMR. They can assist public health systems to construct more effective interventions that account for the complex mediation of the antimicrobial message, and address unintended

consequences such as the amplification of social inequality and the erosion of public trust.

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0.1

08

0/1

74

41

69

2.

20

17

.13

36

24

8

6

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Davis, M.

Willy nilly’ doctors, bad patients, and

resistant bodies in general public explanations of antimicrobial

resistance

Soci

ol H

ealt

h Il

ln

20

20

Au

stra

lia

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y

Publics rely on a heavily inscribed understanding of the body defending itself against microbes. They also read

antibiotic misuse and overuse messages as the responsibility of other patients and medical

practitioners, and not themselves. Significantly, the scientific world view that has created expert knowledge

about AMR hails publics in ways that discredits them and limits their capacity to take action.

Increased engagement with publics will be required to ensure that collaborative and sustainable AMR approaches are fashioned for the future. These

approaches would address the social worlds of the general public, working with their expertise to co-

produce the tools they need to safely address AMR and develop hybrid lay/ expert knowledge for antibiotics

and AMR, better fitted to the real world circumstances. This would have the benefit of stepping away from a

deficit model of publics and the discrediting of lay world views, by collaborating with them in terms that are

workable in the myriad social settings in which infections arise and need treatment.

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1/1

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7-

95

66

.13

11

1

Haenssgen, M.

Antibiotics and activity spaces: protocol of an

exploratory study of behaviour,

marginalisation and knowledge

diffusion

BM

J G

lob

Hea

lth

20

18

Thai

lan

d, L

aos

Hu

man

Co

mm

un

ity/

pri

mar

y

care

Pro

toco

l pap

er Microlevel data on treatment seeking behaviour can

contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example,

decision-making constraints, problems of marginalisation and lacking access to healthcare and

competing ideas about desirable behaviour

The activity space framework can help conceptualise and situate people’s antibiotic access and use during

illness

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mjg

h-2

01

7-

00

06

21

Haenssgen, M.

The Consequences of AMR Education and Awareness

Raising: Outputs, Outcomes, and

Behavioural Impacts of an

Antibiotic-Related

Educational Activity in Lao

PDR

An

tib

ioti

cs (

Bas

el)

20

18

Lao

s

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Qu

anti

tati

ve a

nal

ysis

Before and after survey data around the implementation of an AMR educational activity.

Activity-related communication circulated among more privileged groups, which limited its indirect effects.

Among participants, the educational activity influenced the awareness and understanding of “drug resistance”,

whereas the effects on attitudes were minor. The evidence on the behavioural impacts was sparse and

mixed, but the range of possible consequences included a disproportionate uptake of antibiotics from formal

healthcare providers

Our study casts doubt on the continued dominance of awareness raising as a behavioural tool to address antibiotic resistance. Widespread poverty and the

generally low access to public healthcare, even in our peri-urban setting, suggest that solutions to

problematic forms of antibiotic use do not necessarily reside in the domain of awareness raising, but rather in more fundamental areas like access to healthcare and

medicine.

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bio

tics

70

4

00

95

7

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Haenssgen, M.

The social role of C-reactive

protein point-of-care testing to

guide antibiotic prescription in

Northern Thailand

Soc

Sci M

ed

20

18

Thai

lan

d

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Cas

e st

ud

y We find widespread positive attitudes towards the test among patients and healthcare workers. Healthcare

workers use the test to support their negotiations with patients but also to legitimise ethical decisions in an increasingly restrictive antibiotic policy environment.

More research is needed to ascertain effects on prescription behaviour, distributional implications on

different groups of patients, and how the policy environment and healthcare practices, local

perceptions of illness and medicine, and a broader set of contextual and structural factors influence the

nature, effectiveness, and usefulness of point-of-care testing

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0.1

01

6/j

.s

ocs

cim

ed.2

01

8.0

2.0

18

Haenssgen, M.

Antibiotic knowledge,

attitudes and practices: new insights from

cross-sectional rural health behaviour

surveys in low-income and

middle-income South-East Asia

BM

J O

pen

20

19

Thai

lan

d, L

aos

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Qu

anti

tati

ve a

nal

ysis

A cross-sectional health behaviour survey of rural populations. Villagers were aware of antibiotics and

drug resistance but the usage of technical concepts for antibiotics was dwarfed by local expressions like ‘anti-

inflammatory medicine’

Locally specific conceptions and counterintuitive practices around antimicrobials can complicate AMR

communication efforts and entail unforeseen consequences. Overcoming ‘knowledge deficits’ alone will therefore be insufficient for global AMR behaviour change. An expansion of behavioural AMR strategies towards ‘AMR-sensitive interventions’ that address

context-specific upstream drivers of antimicrobial use (eg, unemployment insurance) and complement education and awareness campaigns are needed.

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mjo

pe

n-2

01

8-0

28

22

4

Haenssgen, M.

How context can impact clinical trials: a multi-

country qualitative case

study comparison of diagnostic

biomarker test interventions

Tria

ls

20

19

Vie

tnam

, Th

aila

nd

, Mya

nm

ar (

Bu

rma)

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y

Part of a trial evaluating the introduction of CRP point of care testing. Perceived infectious disease risks,

health system factors, and the demand-side context influenced adherence of health care workers and

patients to the test results. The disease focus of the trial did not correspond closely with expectations about

antibiotic treatment among doctors and patient. Language and popular conceptions of illness emerged as an important pointer for contradictions between implicit assumptions of the intervention and local realities. Our case study was a further example of tension between internationally recommended

guidelines for disease management and local health systems

If interventions fail to appreciate the local context, they risk duplicating other solutions, competing with existing

practices, or producing unintended consequences.

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6/s

13

06

3-0

19

-

32

15

-9

8

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Helliwell, R.

Can resistant infections be

perceptible in UK dairy farming?

Pal

grav

e C

om

mu

n

20

19

Un

ite

d K

ingd

om

An

imal

Inte

nsi

ve f

arm

ing

Eth

no

grap

hic

stu

dy

Farmers and vet, when observing instances of treatment failure, draw on an experiential repertoire that foregrounds the complexities of host-pathogen

interaction, or failings in human behaviour, over pathogen-antibiotic interactions. The knowledge-

practices of both farmers and vets, although adept at identifying and diagnosing infectious disease are not equipped to make resistance perceptible which has

implications for antibiotic use, Veterinarians anticipate resistance when making antibiotic choices. However, because of the absence of farm level knowledge of

resistance this anticipatory logic is informed through the prevalence of resistance ‘at large’.

The current national surveillance regime is potentially inadequate and identifies a need to establish an active

farm-based surveillance regime. Equally, if the knowledge it produces is responsive to the needs of

practitioners and can be usefully synthesised within on-farm decision making, particularly the practices of anticipation demonstrated by vets, then there is

potential to re-shape the boundaries of what is known about AMR infections on farms.

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59

9-0

19

-

02

20

-2

Jamie, K.

The Social and Material Life of Antimicrobial

Clay: Exploring Antimicrobial Resistance, Medicines'

Materiality, and Medicines

Optimization

Fro

nt

Soci

ol

20

20

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Theo

reti

cal c

on

trib

uti

on

Natural antimicrobials, such as plants, honey and clay, are increasingly moving into mainstream antimicrobial research. Alongside this biomedical focus, we suggest

that the social and material lives of these antimicrobial materials require attention to (i) highlight the ways they have been, and continue to be, used in diverse cultures

globally, (ii) explore ways we might theorize these materials within wider AMR debates, and (iii) examine

the impact of antimicrobials’ materiality on their use by patients

Many of the questions at the center of natural antimicrobials (e.g., the nature of the stuff itself, its

movement into biomedicine and its commercial value) are shared across disciplines and best addressed

through collaborative approaches. Networks spanning social, biological physical, and earth sciences to

promote a holistic approach to social and material life. should be developed.

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soc.

20

20

.

00

02

6

9

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Khine-Zaw, Y.

A Comparison of Patients' Local Conceptions of

Illness and Medicines in the

Context of C-Reactive Protein

Biomarker Testing in Chiang Rai and Yangon

Am

J T

rop

Med

Hyg

20

18

Mya

nm

ar (

Bu

rma)

, Th

aila

nd

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y

A qualitative study, part of a trial evaluating the introduction of CRP point of care testing. Testing

interacted with fever patients' pre-existing conceptions of illness and medicines, their treatment-seeking

behaviour, and their health-care experiences, which led to new interpretations of the test, unforeseen exclusion patterns, implications for patients' self-assessed illness severity, and an increase formal health-care facilities

status. The mismatch between local illness conceptions and inbuilt assumptions of clinical interventions can potentially reproduce problematic equity patterns

Recognising the diagnostic process extends beyond the point of care technology, implementers may consider applying the test after clinical examination to validate

rather than direct prescription processes.

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jtm

h.1

7-0

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6

King, R.

A process for developing a

sustainable and scalable

approach to community

engagement: community

dialogue approach for

addressing the drivers of antibiotic

resistance in Bangladesh

BM

C P

ub

lic H

ealt

h

20

20

Ban

glad

esh

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Cas

e st

ud

y

A community engagement intervention was co-produced and was explicitly designed to link into

existing health system and community structures, and be appropriate for the cultural context. It has the

potential to be implemented at scale. We anticipate that taking this approach increases local ownership, as

well as the likelihood that the intervention will be sustainable and scalable.

Community engagement interventions should ensure that a range of stakeholders coproduce the

intervention, and that the intervention is designed to be appropriate for the health system, community and

cultural context.

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09

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3-5

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Kirby, E.

Medical authority,

managerial power and

political will: A Bourdieusian

analysis of antibiotics in the

hospital.

Hea

lth

(Lo

nd

on

)

20

18

Au

stra

lia

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

We explore hospital managers; accounts of responding to antimicrobial resistance, managing antibiotic

governance and negotiating clinical and managerial priorities. Managers’ accounts articulate the

problematic nexus of measurement and accountability, the downflow effects of political will, and core tensions

within the hospital between moral, managerial and medical authority.

Antibiotic use optimisation will necessitate a degree of jurisdictional re-negotiation between managers and

doctors within which competing forms of capital within the hospital will feature prominently. Addressing antibiotic use requires an acknowledgement that

neither doctors nor managers have absolute power and are rather caught in an ongoing negotiation of capital

and authority.

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36

34

59

31

77

15

77

5

Krockow, E.

The international dimensions of antimicrobial

resistance: Contextual

factors shape distinct ethical challenges in

South Africa, Sri Lanka and the

United Kingdom

Bio

eth

ics

20

18

Sou

th A

fric

a, S

ri L

anka

, Un

ite

d

Kin

gdo

m

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

Structural and cultural contexts impact on the prominence of different ethical dimensions of the antimicrobial resistance dilemma which involves

balancing apparently opposed interests of current and future patients. These dimensions are the visibility and moral equality of future generations; Rule of Rescue; prescribing autonomy and conflicts of interest; and

consensus on collective action. In the private sectors, economic incentives can substitute for morally and

ethically based solutions,

A nuanced understanding of national prescribing dilemmas is critical to inform the design of effective

stewardship approaches. Engaging doctors in collective efforts to preserve antimicrobial efficacy needs to be

balanced, particularly in low‐ and middle‐income countries, by supporting them to optimize their

prescribing without significantly increasing immediate mortality risks. Economic incentives and sanctions in

the private setting need to line up with collective goals for the conservation of antimicrobial efficacy

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4

11

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Krockow, E.

Balancing the risks to individual

and society: a systematic review and synthesis of qualitative

research on antibiotic

prescribing behaviour in

hospitals

J H

osp

Infe

ct

20

19

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al

Rev

iew

Systematic review of qualitative research (34 studies, 6 from LMICs). The Health Belief Model was used as an

analytic framework. The abstract and long-term consequences of AMR led physicians to doubt personal

susceptibility. While they believed in the benefits of optimizing prescribing, the direct link between over-prescribing and AMR was questioned. Changing their

behaviour was considered futile when fighting this complex problem. The salience of individual patient

risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum

antibiotics to be effective and low risk; it involved low cognitive demand and enabled physicians to manage

patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by heightened uncertainty and risk due to poor microbiology and

infection control services

Consider ways through which the perception of the risk of AMR can be made more immediate. Develop evidence show that interventions to optimize

prescribing are effective in slowing the spread of resistance. Feedback on prescribing patterns may foster a recognition of personal responsibility. Consider how to make visible, and reward, conservative prescribing, and how to manage the risk associated with decisions not to prescribe; for example, through organizational

protection from personal litigation. In LMICS, new technology to support improved diagnostic testing and

the provision of microbiology services will reduce diagnostic uncertainty. Improved access to expert

support from microbiology services and pharmacists will also help. In LMICs, a more complex approach is

needed with any interventions for behavioural change accompanied by a tightening of antibiotic sales

regulations and improvements of general hygiene levels

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.jhin

.20

18

.08

.00

7

Lambert, H.

Antimicrobial resistance,

inflammatory responses: a comparative analysis of

pathogenicities, knowledge

hybrids and the semantics of antibiotic use

Pal

grav

e C

om

mu

n

20

19

Ch

ina

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy Patterns of antibiotic use are the result of sociocultural,

economic and systems drivers within a medical context that draws on precepts from both biomedicine and

Chinese medical knowledge. E.g. systems incentives and payment arrangements within the healthcare systems,

the desire for fast treatment by agricultural workers who cannot afford time off work or grandparents who

need to care for grandchildren.

The focus on individual behaviour change should be complemented by greater attention to dynamic and collective processes of knowledge acquisition, the

contingent and plural nature of scientific knowledge, and the semantic and sociocultural, economic and systems influences that shape the actions of health

professionals, patients and publics alike.

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-y

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Langford, B.

Cognitive bias: how

understanding its impact on antibiotic

prescribing decisions can help advance antimicrobial stewardship

JAC

An

tim

icro

b R

esis

t

20

20

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al

Rev

iew

Cognitive biases can contribute to suboptimal antibiotic prescribing. Common cognitive biases in antibiotic prescribing included hyperbolic discounting (the

tendency to favour small immediate benefits over larger more distant benefits) and commission bias (the

tendency towards action over inaction).

Management of cognitive bias includes encouraging more mindful decision making (e.g., time-outs,

checklists), improving awareness of one’s own biases (i.e., meta-cognition), and designing an environment

that facilitates safe and accurate decision making (e.g., decision support tools, nudges). A basic understanding of cognitive biases inspire more creative strategies to

ensure antibiotics are used more safely and more effectively in our patients. h

ttp

s://

do

i.org

/10

.10

93

/ja

cam

r/d

laa1

07

Lohm, D.

Role crisis, risk and trust in Australian

general public narratives about

antibiotic use and antimicrobial

resistance Hea

lth

, Ris

k &

So

ciet

y

20

20

Au

stra

lia

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y

The participants expressed their desire to act in a responsible manner. However, there was considerable

confusion. Despite the encouragement of personal responsibility for health decisions, sick individuals are

urged to abdicate personal decision-making powers and invests trust in the expertise of prescribers. This

assumption is disrupted by 1) patients’ contingencies when circumstances force them to seek and use

antibiotics despite their misgivings, 2) patients’ own embodied knowledge and assessment of their

vulnerability and 3) doubts in the expert knowledge of clinicians. Accordingly, lay publics are left entangled in

contrary expectations of responsibility and trust regarding the use of antibiotics.

Antimicrobial stewardship focusses predominantly on limiting the use of antibiotic treatments to only those

cases where their effectiveness is certain and to safeguarding that they are only used as explicitly

directed by medical practitioners. Such strategies may, on the surface, appear to be simple and unproblematic yet our findings suggest that there are complex reasons

why such a policy may face difficulties in implementation.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Lorencatto, F.

Driving sustainable change in

antimicrobial prescribing

practice: how can social and

behavioural sciences help J

An

tim

icro

b C

hem

oth

er

20

18

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Rev

iew

We discuss four areas where the behavioural and social sciences can help drive more effective and sustained

behaviour change in antimicrobial stewardship: (i) defining the problem in behavioural terms and understanding current behaviour in context; (ii)

adopting a theory-driven, systematic approach to intervention design; (iii) investigating implementation and sustainability of interventions in practice; and (iv) maximizing learning through evidence synthesis and

detailed intervention reporting.

The potential for behavioural and social sciences to contribute to antimicrobial stewardship is contingent

on the urgent need for more researchers and practitioners in the field to work collaboratively across

disciplines.

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3/j

ac/d

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y22

2

Lucas, P.

Pathways to antibiotics in

Bangladesh: A qualitative study investigating how

and when households

access medicine including

antibiotics for humans or

animals when they are ill

PLo

S O

ne

20

19

Ban

glad

esh

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y Unregulated drug shops provide an essential route to medicines including those prescribed in the formal

sector. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Cost was a

reported barrier to purchasing full courses of antibiotics.

This work illustrates the difficulty of reducing excess use of antibiotics without restricting access. Wherever

licensed suppliers are scarce and expensive, regulations which prohibit supply through unregulated drug shops

risk removing access entirely for many people. The alternative is to improve their practice of drug shops.

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1/j

ou

rnal

.po

ne.

02

25

27

0

Manderson, L.

Prescribing, care and resistance: antibiotic use in

urban South Africa

Pal

grav

e C

om

mu

n

20

20

Sou

th A

fric

a

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy

The social context of patient and provider interactions influenced treatment. Community health centres were stretched for resources with long wait times and brief

consultations. Providers’ treatment decisions were informed by clinical assessment, concern about

bacterial infection risk, and perceptions of patient ability to seek further care. \the provision of a

prescription also reflected clinicians’ appreciation of economic constraint and vulnerability.

The contextual factors that impact vulnerability and risk, including of common colds and flu, need to be

addressed at multiple levels, including through structural and systems changes. However, a slow fix, that might include improvements in quality of care,

working and living conditions, and hygiene and sanitation, remains a relatively distant goal.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

McParland, J.

What are the 'active

ingredients' of interventions targeting the

public's engagement with

antimicrobial resistance and

how might they work?

Br

J H

ealt

h P

sych

ol

20

18

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Rev

iew

The analysis shows very few studies reported any explicit theoretical basis to the interventions targeting

the public's engagement with AMR they described. Many interventions share common components,

including core mechanisms of action and behaviour change techniques.

Few behavioural change theories have been applied in AMR interventions thus providing a clear opportunity

for the development of novel interventions in this context.

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jhp

.

12

31

7

Mitchell, J.

The values and principles

underpinning community

engagement approaches to

tackling antimicrobial

resistance (AMR)

Glo

b H

ealt

h A

ctio

n

20

19

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y ca

re

Mu

ltid

isci

plin

ary

anal

ysis

Seven values underpinning the application of Community Engagement approaches to the One Health challenge of antimicrobial resistance were developed:

Clarity, Creativity, (being) Evidence-led, Equity, Interdisciplinarity, Sustainability and Flexibility

This tool can be used to scene-set, road map and trouble shoot the development, implementation, and

evaluation of community engagement projects to address AMR and other One Health challenges.

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49

71

6.2

02

0.1

83

74

84

Naher, P.

What contributes to inappropriate

antibiotic dispensing

among qualified and unqualified

healthcare providers in

Bangladesh? A qualitative study

BM

C H

ealt

h S

erv

Re

s

20

20

Ban

glad

esh

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy

Antibiotics were considered a medicine of power that gives quick results and works against almost all

diseases. Expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as

preventative medicines. While some providers were well informed about antibiotic resistance and its causes,

others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics. Despite varied knowledge, providers showed concern about antibiotic resistance but

responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of

livestock and animals.

Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic

action and improve practices, more far reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all healthcare practitioners.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Pearson, M.

Knowing antimicrobial resistance in

practice: a multi-country

qualitative study with human and

animal healthcare

professionals

Glo

b H

ealt

h A

ctio

n

20

19

Eth

iop

ia, I

nd

ia, N

iger

ia, P

hili

pp

ines

, Sie

rra

Leo

ne,

Vie

tnam

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy

Contextual factors that influenced prescribing and dispensing included antibiotic accessibility and affordability; lack of local antibiotic sensitivity

information; concerns over hygiene and sanitation; and interaction with medical representatives.

Increasing awareness of AMR will be insufficient to change prescribing and dispensing without local

information on which antibiotics do work well, without investment in infrastructure that allows antimicrobials to be released from their ‘band aid’ role, and without active regulation of pharmaceutical representatives.

Policy that addresses infection prevention must address the infrastructural context of hygiene if it intends to impact prescribing practices. Policy must address the

need for information by local practitioners in regulatory frameworks if reliance on potentially unreliable profit orientated information sources is to be avoided. More

research is needed to explore not just the role and influence of medical representatives along the

antimicrobial supply chain, acknowledging the multiple levels, agendas and motivations of the pharmaceutical

industry. htt

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49

71

6.2

01

9.1

59

95

60

Price, L.

Effectiveness of interventions to

improve the public’s

antimicrobial resistance

awareness and behaviours

associated with prudent use of

antimicrobials: a systematic

review

J A

nti

mic

rob

Ch

emo

ther

20

18

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Rev

iew

Systematic review (19/20 studies from high income countries). The studies were heterogeneous and the

quality of evidence was poor. Seventeen studies demonstrated a significant effect on changing

knowledge, attitudes or the public’s antimicrobial stewardship behaviours. Analysis showed that

interventions targeting schoolchildren and parents have notable potential, but for the general public the picture

is less clear.

The development of well-designed AMR-related interventions robustly grounded within behavioural and

social science theory are needed. Well-designed, experimental studies on behavioural outcomes of such interventions are also required. We suggest that future policy makers should consider multimodal segmented

population-level intervention that tailors its core messages to children, parents and the wider general public alike, particularly in high-income geographical

areas

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16

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Rodrigues, C.

Self-medication with antibiotics in

Maputo, Mozambique:

practices, rationales and relationships P

algr

ave

Co

mm

un

20

20

Mo

zam

biq

ue

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy

Antibiotics and other prescription-only pharmaceuticals were seldom used as a first resort. Practices of and

attitudes towards self-medication with antibiotics are shaped by personal and socially shared experiences, articulated with forms of knowledge and information

provided by different sources including relatives’, neighbours’ and health professionals. Health

professionals, both prescribers and dispensers were influential. Situated rationales of certain consumption

practices do not always follow biomedical recommendations of ‘rational/appropriate use’. We

need to understand and situate the rationales behind those practices, and the relational and structural factors

behind such rationales.

It is important to examine the social, cultural, political and economic contingencies that may influence

different antibiotic needs and modalities of use, in context and to engage with all of the different local

actors to improve antibiotic use. Individuals’ rationales should not be seen as part of the problem, but should rather be incorporated into the solution. We need to: improve the quality of communication in therapeutic

encounters, between providers and users; adjust health campaign messages to use more contextually-

significant vocabulary; adjust regulatory measures to local realities. Policy enforcement to prohibit over the

counter sales in retail pharmacies need to balance restriction vs. access and to consider geographical

inequalities. Regulatory measures and interventions need to consider the availability of antibiotics through illegal or informal channels, which may represent an

even bigger challenge.

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59

9-0

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85

-8

Saukko, P.

Gaps in communication

between different staff

groups and older adult patients

foster unnecessary

antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach

An

tim

icro

b R

esis

t In

fect

Co

ntr

ol

20

19

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

Inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older

adult patients, using different languages and technologies or interpreting them differently.

Interventions to improve diagnosis and antibiotic prescribing for urinary tract infections in older adults

have typically focused on educating clinicians. However, addressing gaps in communication between clinicians and patients and between different staff groups and clinical domains could importantly enhance hospital antimicrobial stewardship efforts and interventions. This could include developing advice for clinicians on

how to not only recognise but also communicate with older patients about symptoms. Promoting shared understanding of the process of urinalysis between

diverse staff, patients and clinical domains could also improve practices and reduce unnecessary antibiotics

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6-0

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87

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Saukko, P.

Diagnosis Between Chaos

and Control: Affect and Hospital

Clinicians' and Older Adult

Patients' Narratives of Urinary Tract

Infections”

Fro

nt.

So

cio

l

20

20

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

Some clinicians and patients articulated chaos narratives about being overwhelmed by contradictory

evidence and events, doubting the repeated UTI diagnoses and courses of antibiotics but being unable

to do anything about their concerns. Others articulated control narratives about UTIs being frequently diagnosed and antibiotics prescribed to restore

patients’ health, echoing certainty and security, even if the processes described typically did not follow current guidance. Our findings complicate notions of patients

pressuring for antibiotics.

There is a rarely examined or acknowledged affective underlay that shapes clinicians’ and patients’

understandings and actions vis a vis diagnosis and antibiotic prescribing. To address this affective

dimension would likely require a more conversational and cooperative approach to improving diagnosis and

prescribing

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9/f

soc.

20

20

.00

05

7

Snively-Martinez, A.

Ethnographic Decision

Modeling to Understand Smallholder

Antibiotic Use for Poultry in

Guatemala Med

ical

An

thro

po

logy

20

19

Gu

atem

ala

An

imal

Smal

lho

lder

s

Eth

no

grap

hic

stu

dy

There is little access to professional vets and veterinary medications, local farm and feed shops fill the role of professional vet care and are often the only interface

for rural farmers’ information regarding vet medicines. Remote communities have limited access to even feed

shops that sell OTC veterinary medications. Smallholder households, rely on information from neighbors and

local storeowners regarding poultry treatment. If they feel there is a need to administer biomedicines to their

poultry, they commonly resort to purchasing human antibiotics, which are occasionally miraculous and are

widely available at local pharmacies and shops.

Access to veterinary medicine and education campaigns on poultry health are necessary to support the

appropriate use of antimicrobials for backyard poultry

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59

74

0.2

01

8.1

55

07

55

Tarrant, C.

Optimizing antibiotic

prescribing: collective

approaches to managing: a

common-pool resource

Clin

Mic

rob

iol I

nfe

ct

20

19

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al

Rev

iew

A narrative review of literature on interventions to promote the conservation of resources in social

dilemmas. The social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and

the outcome of AMR, and the agency relationships inherent in the prescriber role.

A theory base for future interventions seeking to shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of

antibiotic efficacy is provided: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable

collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational

incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution

mechanisms. htt

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Thompson, W.

Clinician and Patient Factors

Influencing Treatment Decisions:

Ethnographic Study of

Antibiotic Prescribing and

Operative Procedures in

Out-of-Hours and General Dental

Practices.

An

tib

ioti

cs

20

20

Un

ite

d K

ingd

om

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy

Beliefs about antibiotics, goals for the appointment and access to dental services were important for both

dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures

on patients. Patient factors included their communication and negotiation skills. Contextual

elements included dentists’ concerns about inflicting pain on regular patients; and patients’ difficulties

accessing care in out of hours.

This improved understanding of factors influencing shared decisions about treatments presents significant

opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions. “one

size fits all” approach to antibiotic stewardship is unlikely to be successful. Access to primary and

secondary care dental services was found to be an important environmental factor impacting on both

dentists and patients. Significant opportunities exist for the design of new evidence-based, theory-informed

contextually fit approaches to tackle unnecessary antibiotic use

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nti

bio

tics

90

90

57

5

Wang, X.

Determinants of non-prescription

antibiotic dispensing in

Chinese community

pharmacies from socio-ecological

and health system

perspectives

Soc

Sci M

ed

20

20

Ch

ina

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y

Non-prescription antibiotic dispensing was driven by fierce competition between community pharmacies and by customers' expectations. At the institutional

level, community pharmacies to evades the Food and Drug Administration's supervision by obtaining

unsupervised and fake prescriptions, refusing to give customers sale receipts, and hiding their antibiotic

supplies and sale records. At the policy level, the low cost of violating the prescription only antibiotic sale regulation and poor FDA supervision facilitated non-

prescription antibiotic dispensing

Proposed interventions to reduce non-prescription antibiotic dispensing are: education campaigns to

increase awareness about the risks of self-medication with antibiotics among the general public, recognizable

standardize prescriptions for customers to fill their prescriptions in community pharmacies, regulations on Internet and private clinic doctors' antibiotic prescribing

behaviors, electronic tracking and tracing system to purchases and sales data of antibiotics and other prescription drugs, increasing cost of violating the prescription only regulations for antibiotics sales

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Whittaker, A.

Investigating Understandings

of Antibiotics and Antimicrobial Resistance in

Diverse Ethnic Communities in

Australia: Findings from a

Qualitative Study

An

tib

ioti

cs (

Bas

el)

20

19

Au

stra

lia

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Inte

rvie

w s

tud

y

There was poor understanding of antimicrobial resistance. Causes of the increasing incidence of AMR were attributed to: weather fluctuations and climate change; a lack of environmental cleanliness; and the

arrival of new migrant groups. Antibiotics were viewed as ‘strong’ medicines that could potentially disrupt this balance and weaken the body. Travel back to countries

of origin sometimes involved the use of medical services and informants noted that some imported

antibiotics from overseas. Most used the internet and social media to source health information. There is a

lack of information in their own languages

More attention needs to be given to migrant communities who are vulnerable to the development, transmission and infection with resistant bacteria to

inform future intervention. Public health AMR messages require a sensitivity to the role of cultural diversity in understandings and practices regarding

antimicrobial use. A multidisciplinary evidence base on AMR – including sociology and anthropology - which

takes into account the context of pharmaceutical usage, social relationships involved in their use and the

experiences and knowledges of diverse communities will assist health practitioners and policy makers to design and deliver targeted education campaigns,

community-led peer interventions and regulations that can improve decision making about antimicrobial stewardship by all members of our communities

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tics

80

30

13

5

Will, C.

From universal frames to collective

experimentation? Pursuing serious

conversations about

antimicrobial resistance

Wel

lco

me

Op

en R

es

20

20

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

Dis

cou

rse

/ d

ocu

me

nta

ry a

nal

ysis

Analysis of the Wellcome Trust’s report: “Reframing resistance: How to communicate about antimicrobial

resistance effectively”. We locate the Wellcome Trust’s report in the field of social science work on AMR. Writing against the backdrop of the COVID-19, we

explore how AMR raises questions about our attachment to modern medicine, about the motivating

value appeals to vulnerability and health inequality.

If we want to improve communication of AMR to policy makers and to different lay constituencies, we should

engage with the multiplicity of stakes in and experiences of antibiotic use to find ways of sparking

curiosity and emotional engagement. In particular much of the difficult politics of AMR is missed if we do

not pay attention to either industrial production or inequality and vulnerability. Policy focussed

recommendations should continue to develop in discussion with social scientific and bioethics work, and

social scientists and bioethicists should endeavour to publish in ways that are accessible and understandable

to non-academic audiences. The multiplicity of AMR meanings and practices should open up a platform for communicators to also be multiple in their metaphors, frames and imaginings of bacteria and its mechanisms

of resistance

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – PRACTICES (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Will, C.

The problem and the productivity

of ignorance: public health campaigns on

antibiotic stewardship.

Soc

Rev

20

20

Un

ite

d K

ingd

om

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Dis

cou

rse

/ d

ocu

me

nta

ry a

nal

ysis

This article describes efforts to engage people with the issue of AMR. It analyses how public health workers

encourage what they understand as responsible antibiotic use or antibiotic stewardship, and how their efforts are shaped by different theories of ‘behaviour’ or social action. Different versions of the citizen jostle

for attention in a public health that draws on sociology, psychology, and increasingly behavioural economics. I suggest the term ‘shrug’ as a provocative counterpart

to the ‘nudge’ of behavioural economics, drawing attention to the ways in which behavioural

interventions may be linked to strategic retreats from engagement.

Narrow forms of behavioural thinking shape relations between governments and their citizens. For example, uses of ignorance reduce the space for other kinds of

public engagement around AMR. Alternative approaches should be considered.

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26

11

98

87

33

0

Zhou, L.

Pathways to optimising

antibiotic use in rural China:

identifying key determinants in community and

clinical settings, a mixed methods study protocol.

BM

J O

pen

20

20

Ch

ina

Hu

man

Co

mm

un

ity/

pri

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y ca

re

Pro

toco

l pap

er

This study will document key drivers of, and patient pathways leading to, antibiotic use and establish the

feasibility of microbiological testing and epidemiological monitoring for AMR and antibiotic use at frontline medical settings in rural China. The mixed methods approach will provide a comprehensive picture of

factors influencing prescribing and sampling practices so that bias arising from any individual dataset can be

accounted for in the analysis and interpretation of results strengthened through triangulation.

There is a need for comprehensive and systematic assessment of prescribing and purchasing practices in

the context of China’s unique health systems and policies, to identify potential targets for interventions to optimise prescribing and consumption. There are

also crucial gaps in evidence regarding antibiotic resistance and its determinants in rural communities and health facilities at village and township levels in

China and it is important to investigate the possibility of introducing routine monitoring of prevalence and

epidemiology of AMR in these settings.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Afari-Asiedu, S.

Determinants of Inappropriate

Antibiotics Use in Rural Central Ghana Using a

Mixed Methods Approach.

Fro

nt

Pu

blic

H

ealt

h

20

19

Gh

ana

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Mix

ed-m

eth

od

s

The qualitative component described the influence of cost of medicines on inappropriate antibiotic use. It also

revealed that antibiotic users with low socioeconomic status purchased antibiotics in installments which, could

facilitate inappropriate use.

To improve appropriate antibiotic use, there is the need for ministry of health and healthcare agencies in Ghana to enhance healthcare access and healthcare insurance, and

to provide affordable antibiotics

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ub

h.2

02

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0

Biswas, D.

An ethnographic exploration of

diarrheal disease

management in public hospitals in Bangladesh: From problems

to solutions.

Soc

Sci M

ed

20

20

Ban

glad

esh

Hu

man

Ho

spit

al

Eth

no

grap

hic

stu

dy Conflict between 'what should be done' and 'what can be

done' was the most common challenge identified. Factors that prevented clinical guideline adherence (eg antibiotic

prescription) included human resource constraints, conflicts of interests, overcrowding, and inadequate

hygiene and sanitation in the emergency department and wards.

Educate doctors, nurses and medical staff using ‘job aids’, posters and placards. Introduce vinyl ‘cholera cots’ that collect waste in a bucket below the cot for those unable to use the restroom. Ensure cleaning supplies. Provide a performance-based incentive structure. Investment in

sufficient weight-scales, soap, sinks, and toilets. A behavior change intervention for providers and patients on setting expectations for sanitation, hygiene and the

benefits and risks of antibiotics. Expectations must be set such that guidelines can be followed yet be

accommodating for the realities of resource-limitations. Reduce workload of the admitting physicians by enabling

physician assistants to assess and initiate diarrheal treatment. Hiring and adequately compensating custodial

staff. Develop an institutional policy on how best to engage with the pharmaceutical companies. Prescribing generic named drugs instead of brand named antibiotics may reduce cost and pharmaceutical influence. Creating policies on how to balance private and public practices. h

ttp

s://

do

i.org

/10

.10

16

/j.s

ocs

cim

ed.2

02

0.1

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18

5

Blanchette, C.

Living Waste and the Labor of Toxic Health

on American Factory Farms. M

ed A

nth

Q

20

19

Un

ite

d S

tate

s o

f

Am

eric

a

An

imal

Inte

nsi

ve f

arm

ing

Inte

rvie

w s

tud

y This article develops an ethnography of excrement by tracing the practices and knowledge of people who live

and labor in proximity to late industrial lifeforms, such as confined pigs and resistance genes, and who are tasked with intimately shaping this unruly waste that has the

potential to affect broader populations.

We need to address the political-economies of labour not only among human workers and the conditions of these subjects’ lives, but also with the conditions of material “objects”— pigs and fecal microbes alike—that make

work as it is today

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES (Cont.)

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Broom, A.

Antimicrobial resistance as a problem of values? Views from three continents.

Cri

tica

l Pu

blic

Hea

lth

.

20

20

Au

stra

lia, I

nd

ia, U

nit

ed

Kin

gdo

m

Hu

man

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Inte

rvie

w s

tud

y We approach the problem of AMR as one of values and culture rather than of individual behaviour. We reframe

AMR as a social and political concern resulting from a confluence of factors and practices including: temporal

myopia, individualisation, marketisation, and human exceptionalism

To effectively tackle AMR, we advocate solidaristic models that espouse collective responsibility and recognise relative opportunity to act. Instead of stewardship programs which are punitive at the

individual level (‘bad prescribers’, ‘good prescribers’), a systemic approach to countering AMR would direct

attention to addressing the financial and reputational incentives for institutions and for the people working in

them. htt

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44

Broom, J.

Antimicrobial overuse in

India: A symptom of

broader societal issues including

resource limitations and

financial pressures

Glo

b P

ub

lic H

ealt

h

20

20

Ind

ia

Hu

man

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Inte

rvie

w s

tud

y Financial pressures, social pressures and uneven

regulation all contribute to over-prescribing. Escalating antimicrobial resistance, and mortality associated with infections caused by multi-drug resistant organisms, is likely increase (appropriately) fear related to adverse

patient outcomes, and make narrow spectrum prescribing increasingly difficult

Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change. In this context, the pressures

to prescribe/dispense not always diagnostic or infrastructure related, but social pressures, relating to

both patient expectations and financial pressures. These may be modifiable. Considerable additional work is need to examine the social and cultural ‘determinants’ of AMR

across India’s vast and varied landscapes.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES (Cont.)

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Chandler, C.

Current accounts of

antimicrobial resistance:

stabilisation, individualisation and antibiotics

as infrastructure

Pal

grav

e C

om

mu

n

20

19

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

Theo

reti

cal c

on

trib

uti

on

AMR presents an inversion of the current status quo rendering visible the ways in which our lives are

contingent upon antimicrobial medicines: to define and deliver health care; to enable productivity of work forces,

industrialisation of food other commodities; as well as making possible particular social and political values in

the context of modernisation, urbanisation and globalisation. In this sense, antimicrobials can be

considered as infrastructure—as usable systems that disappear unless deliberately explicated.

Recognising the infrastructural roles of antibiotics opens-up possibilities for reconfiguring AMR research and action

by shifting the focus of attention across scales and enabling different forms of care, and different publics, to come into view. Such shifts enable us to conceive of AMR

not only as ‘The End of Modern Medicine’ but as an invitation to an era of medicine beyond that defined

through modernity

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9-

01

9-0

26

3-4

Collingnon, P.

Anthropological and

socioeconomic factors

contributing to global

antimicrobial resistance: a

univariate and multivariable

analysis

Lan

cet

Pla

net

Hea

lth

20

18

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Qu

anti

tati

ve a

nal

ysis

Reduction of antibiotic consumption will not be sufficient to control AMR resistance because contagion-the spread of resistant strains and resistance genes-seems to be the

dominant contributing factor.

Improving sanitation, increasing access to clean water, and ensuring good governance, as well as increasing

public health-care expenditure and better regulating the private health sector are all necessary to reduce global

antimicrobial resistance.

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25

4

2-5

19

6(1

8)3

01

86

-4

Denyer Willis, L.

Quick fix for care,

productivity, hygiene and inequality:

reframing the entrenched problem of antibiotic overuse

BM

J G

lob

Hea

lth

20

19

Tan

zan

ia, U

gan

da

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy This paper explores what roles antibiotics play beyond

their immediate curative effects. antibiotics have become a 'quick fix' in our modern societies. They are a quick fix

for care in fractured health systems; a quick fix for productivity at local and global scales, for humans,

animals and crops; a quick fix for hygiene in settings of minimised resources; and a quick fix for inequality in

landscapes scarred by political and economic violence.

Conceptualising antibiotic use as a 'quick fix' infrastructure shifts attention to the structural

dimensions of AMR and antimicrobial use (AMU) and raises our line of sight into the longer term, generating

more systemic solutions that have greater chance of achieving equitable impact.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES (Cont.)

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Doron, A.

The Spectre of Superbugs:

Waste, Structural

Violence and Antimicrobial Resistance in

India.

Wo

rld

wid

e W

aste

20

20

Ind

ia

Hu

man

Co

mm

un

ity/

pri

mar

y

care

Theo

reti

cal

con

trib

uti

on

We explore emerging geographies of vulnerability by examining the nexus of environmental pollution, waste-

work, poverty and the decreasing viability of antimicrobials. Such spaces render poor people and their

environment more exposed to infectious agents due to socio-cultural processes and environmental conditions.

Political will and tightened regulations are urgently required. Population density, poor sanitation, the

magnitude of waste and scarcity of clean water mean that bacterial risk, and accompanying use of microbials,

will grow and need addressing. The study of Indian conditions should be a priority to understand the

development and spread of AMR.

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wj.2

0

Haenssgen, M.

Precarity and clinical

determinants of healthcare-

seeking behaviour and

antibiotic use in rural Laos and

Thailand

BM

J G

lob

Hea

lth

20

20

Thai

lan

d, L

aos

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Qu

anti

tati

ve a

nal

ysis

The link between clinical presentation and antibiotic use was surprisingly weak. Instead, patients in precarious circumstances were significantly more likely to misuse

antibiotics in the presence of situational facilitators (eg, mobile phones and social support activated during an

illness).

Development processes that change whether and how people experience precarious circumstances could have

unforeseen implications for collective global health threats such as AMR. Global health interventions must

move beyond patient-centric and disease-centric approaches, acknowledging and responding to contextual

factors that shape how people cope with illness and consider ‘AMR-sensitive development policy’. If precarity as a social determinant continues to be neglected, then localised forms of hardship could unwittingly influence and undermine the effectiveness of existing clinical and

behavioural interventions to tackle AMR.

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37

79

Kirchhelle, C.

A Biohistorical Perspective of Typhoid and Antimicrobial Resistance. C

lin In

fect

Dis

20

19

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

His

tori

cal a

nal

ysis

We reconstruct the biosocial history of AMR in the bacterium Salmonella enterica serovar Typhi (S. Typhi) showing how its evolutionary divergence was driven by rising global antibiotic use and by the neglect of typhoid

outside of high-income countries. Antibiotic-intensive compensation for weak water and healthcare systems

subsequently fuelled AMR selection in low- and middle-income countries but often remained invisible due to

lacking surveillance capabilities.

International funding, and policy agendas extending beyond biosecurity would help foster a co-ordinated and

global collective action for typhoid control.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES (Cont.)

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Masud, A.

Drivers of Antibiotic Use

in Poultry Production in Bangladesh:

Dependencies and Dynamics of a Patron-

Client Relationship

Fro

nt

Vet

Sci

20

20

Ban

glad

esh

An

imal

Smal

lho

lder

s

Inte

rvie

w s

tud

y

Poultry dealers provide credit and information for small-scale poultry farmers. In return, farmers are obliged to buy poultry feed and medicine, and sell their market-

ready poultry to that same dealer. Poultry dealers were the main influencers of decision-making by farmers,

particularly around antibiotic use as an integral part of the production cycle risk management.

Strategies to improve antibiotic stewardship and responsible use should exploit the patron-client

relationship which provides the social and information network for small-scale farmers. Regulation, monitoring,

and control programs for the prudent use of antibiotics in food-producing animals must begin with feed

manufacturers and small/medium-scale poultry industries

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9/f

v

ets.

20

20

.00

07

8

Rousham, E.

Human, animal and

environmental contributors to

antibiotic resistance in low-resource

settings: integrating

behavioural, epidemiological and One Health

approaches

Pro

c B

iol S

ci

20

20

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y ca

re

Rev

iew

A review of the extent of One Health research on antibiotic resistance. Very few studies have integrated all three components of the One Health spectrum (humans,

animals and the environment) to understand the dynamics of transmission and the prevalence of

community-acquired resistance in humans and animals.

Microbiological, epidemiological and social science research is needed at community and population levels across the One Health spectrum in order to fill the large

gaps in knowledge of ABR in low-resource settings.

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.

03

32

27

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES (Cont.)

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Tarrant, C.

Moral and Contextual

Dimensions of “Inappropriate”

Antibiotic Prescribing in

Secondary Care: A Three-Country

Interview Study

Fro

nt.

So

cio

l

20

20

Sou

th A

fric

a, S

ri L

anka

, Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms.

Prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the

threshold for appropriate use. Some drew on arguments about their duty to protect public health, while others

prioritised risk avoidance for the patients in front of them, even at a cost of increased resistance. There was

significant ambiguity about judgements of appropriateness of antibiotic use in case of diagnostic

uncertainty. High levels of antibiotic prescribing could be seen as a rational response when prescribers were

working in challenging contexts, and could be justified in relation to financial and social considerations

Rather than assuming that inappropriate prescribing can be objectively specified, more support is needed for

prescribers in managing uncertainty, e.g. through approaches to support empirical decision making,

improve documentation of rationale for antibiotic use, and reviews of antibiotic prescriptions (based on updated

information providing more certainty, such as microbiology results). There is also a need to address the moral aspects of prescribing decisions through vignette-based debates and providing opportunities for collective

input to difficult decisions. The establishment of collective agreements around the duty of prescribers to

consider the interests of society in making antibiotic prescribing decisions should be considered. Efforts to

reduce inappropriate antibiotic use by targeting prescribing behaviour may be futile if they fail to address

local cultural and contextual conditions such as poorly integrated health systems particularly in resource limited

settings. A more holistic approach should consider the broader drivers of antibiotic use including sanitation,

community healthcare, and the financial implications for patients of hospitalization.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – STRUCTURES (Cont.)

Lead author

Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Tarrant, C.

Drivers of Broad-Spectrum

Antibiotic Overuse across Diverse Hospital

Contexts—A Qualitative

Study of Prescribers in

the UK, Sri Lanka and

South Africa

An

tib

ioti

cs (

Bas

el)

20

21

Sri L

anka

, So

uth

Afr

ica,

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Inte

rvie

w s

tud

y

Their features of wide coverage, effectiveness, and ease of deployment mean that broad spectrum antibiotic use

becomes a simple solution to challenges arising from structural constraints and limitations. These vary across

healthcare settings in countries with different health systems and levels of resource. They include structurally embedded risks and perverse incentives, social norms,

missing infrastructure, and patient poverty. Social influences were most powerful in private hospital

settings, where social norms around prescribing and clinical autonomy were strong drivers

Efforts to optimize antibiotic use need to go beyond correcting individual prescribing behaviour as reliance on

broad spectrum antibiotics can result from local social and structural conditions that constrain the possibilities for action. Antimicrobial stewardship should include a focus on identifying alternative, contextually-sensitive,

solutions to these structural issues. Structural issues may include sanitation, infection prevention policy and

planning, improvements to medicines regulation, and investment in diagnostic facilities and healthcare

facilities. Resolving these types of drivers requires extensive investment and regulatory and policy

intervention. Other low-cost and contextually-sensitive solutions might help reduce reliance on antibiotics eg

focusing microbiology resources to patient groups where they have the highest impact. It can also prompt us to ask different questions depending on the underlying drivers

of overuse for example: How can we ensure that doctors feel safe and supported to reduce antibiotic use in the context of organizational priorities and national drivers

around reducing mortality from infection; How might we enable doctors to attract patients and succeed in private practice through building a reputation as a responsible prescriber of antibiotics; What low-cost interventions

would help reduce the risk of infection, encourage help seeking, and enable early and effective treatment in

resource-poor communities; How can we design infection control interventions that are feasible in

suboptimal hospital environments; How could pricing systems in private hospitals be redesigned to remove

perverse incentives for using broad spectrum antibiotics?

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Begemann, S.

The Governance of UK Dairy

Antibiotic Use: Industry-Led

Policy in Action. Fro

nt

Vet

Sci

20

20

Un

ite

d K

ingd

om

An

imal

Inte

nsi

ve f

arm

ing

Eth

no

grap

hic

stu

dy

Dairy industry policies only partially address the complex network of people, animals, and the

environment in which dairy antibiotics circulate. Antibiotic "misuse and overuse" in agriculture is far from a behavioural matter, with solely farmers and

veterinarians to blame. Instead, antibiotic use in food animals is embedded in complex economic networks that constrain radical changes in dairy husbandry management and antibiotic use on

farms.

Educational strategies, training programmes, and technologies that support antibiotic governance will have a limited impact in changing farmers'

behaviour. More attention toward the ‘needs’ of the dairy supply chain actors and wider

environmental considerations is essential to reduce the dairy sector's dependency on

antibiotics. Rather than contrasting lay knowledge and expert knowledge by referring to terms like

rationality and irrationality, we need a collaboration between different types of antibiotic

knowledges. Vision-building across sectors and disciplines to study AB-use as part of a bigger

picture of animal welfare, environmental impact and sustainable food production is needed. h

ttp

s://

do

i.org

/10

.33

89

/fve

ts.2

02

0.0

05

57

Bellet, C.

Change it or perish? Drug

resistance and the dynamics of livestock farm

practices. J R

ura

l Stu

die

s

20

18

Un

ite

d K

ingd

om

An

imal

Inte

nsi

ve f

arm

ing

Inte

rvie

w s

tud

y

Farmers prioritise farm productivity and animal health and welfare to the detriment of an

adequate use of anthelmintics, which may lead to an increase in drug resistance. As a strategy to

address drug resistance in livestock, mainstream policy approaches to drug management in the

farm have prioritised the development and dissemination of technical guidelines. However,

these guidelines are usually disconnected from the farming context, do not take into account the complexity and challenges of farm everyday

practices and are eventually rejected by farmers. Farm practices related to drug use are situated

within a larger context of intensive animal production systems, which themselves contribute

to the emergence of animal diseases, the medicalisation of animal production and drug

resistance

There is still a need for unpacking the hidden dynamics and logics of farm practices,

understanding how they shape animal health management and, more specifically, drug use. This

will support the development more comprehensive strategies - beyond regulations - against drug resistance. We also need to explore

the roles of other players, such as the food industry and consumers, who are also responsible for defining the structures of the system and the

‘value’ of livestock animals, something that, ultimately, influences the emergence of diseases, the assessment of risks, the practices related to

animal medication and drug resistance itself.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Brazelton, M.

The production of penicillin in

wartime China and Sino-American

definitions of “normal”

microbiology.

J M

od

Ch

ine

se H

20

19

Ch

ina

Hu

man

Scie

nti

fic

circ

les

His

tori

cal a

nal

ysis

The history of domestic penicillin production in China during the Second Sino-Japanese War

illustrates the fragility, difficulty, and historical contingency of antibiotic development.

Questions of the “normal” in biomedical research and development are more relevant than ever when it comes to the production of antibiotics. Historical analysis can help us understand how

ideas of ‘normal’ are reached.

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35

65

4.2

01

9.

16

32

56

3

Brives, C.

Phage therapy as a potential

solution in the fight against

AMR: obstacles and possible

futures.

Pal

grav

e C

om

m

20

20

Bel

giu

m, F

ran

ce,

Swit

zerl

and

Hu

man

Scie

nti

fic

circ

les

Eth

no

grap

hic

stu

dy

Antibiotics form a kind of epistemological infrastructure, which acts as a powerful inhibitor

to the development of phage therapy. In this sense antibiotics prevent the development of solutions

to the problem they contribute to create.

The difficulties phage therapy faces, as highlighted can be interpreted as entrypoints for thinking of another medicine and imagining other possible

futures.

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oi.o

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7/s

41

59

9-

02

0-0

47

8-4

Brives, C. Pluribiosis and

the never-ending microgeohistories

20

21

Bel

giu

m, F

ran

ce,

Swit

zerl

and

Hu

man

Scie

nti

fic

circ

les

Eth

no

grap

hic

stu

dy Observing and learning from viruses and bacteria

gives us an opportunity to understand the term pluribiosis: the recognition of the existence of multiple relational spectra between entities

forever in the process of becoming, constantly shaped and transformed by their interactions with

other living things.

The relational nature of living things is a forgotten element in antibiotic therapy. Phages help us to

remember this dimension and to develop, as many agents in phage therapy hope, a medicine that

actively takes into account pluribiosis.

Brown, N.

Bugs in the blog: Immunitary moralism in

antimicrobial resistance (AMR).

Soc

Theo

ry &

Hea

lth

20

17

Un

ite

d K

ingd

om

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Dis

cou

rse

/ d

ocu

me

nta

ry

anal

ysis

We reveal how the moral politics of blame and immunitary othering are present in online debates

about AMR, and explore the way these registers resonate with philosophical writings on the

ascendency of immunitary individualism and tensions between community and immunity.

Policies focussed on behaviour, we suggest, have the potential to intensify immunitary moralism

with unintended, stigmatising and socially divisive consequences.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Brown, N.

Pathways, Practices and Architectures:

Containing Anti-Microbial

Resistance (AMR) in the Cystic

Fibrosis Clinic.

Hea

lth

(Lo

nd

on

)

20

20

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Eth

no

grap

hic

stu

dy

This article explores AMR in the context of building design and healthcare architecture, focussing on

the layout, design and ritual practices of three cystic fibrosis outpatient clinics

Most attention in policy-making and social science research envisions AMR in terms of ‘behaviour’.

Far less attention has been paid to the way AMR is located spatially and architecturally in a world configured socio-materially through building layout, corridors, waiting rooms, scheduling,

appointment logistics, windows, air ventilation and many of the other aspects of infrastructural design h

ttp

s://

do

i.org

/10

.11

77

%2

F13

63

45

93

19

86

6

89

4

Brown, N.

Architecture and Design for a Post-Antibiotic/Post-Covid-19 World. D

isco

ver

Soci

ety

20

20

Un

ite

d

Kin

gdo

m

Hu

man

Ho

spit

al

Eth

no

grap

hi

c st

ud

y AMR and Covid-19 brings back an attention to the space of the body, its situatedness, its location in structures that are social, material and physical.

A new attention to the space/atmosphere of the body, its location in the built environment, is one

of most powerful assets we have when it comes to tackling infectious disease. h

ttp

s://

dis

co

vers

oci

ety.

org

/20

20

/0

6/1

6/a

rch

it

ectu

res-

and

-

des

ign

s-fo

r-

a-p

ost

-

anti

bio

tic-

po

st-c

ovi

d-

19

-wo

rld

/

Brown, N.

Air care: an ‘aerography’ of

breath, buildings and bugs in the cystic fibrosis

clinic. Soci

ol H

ealt

h Il

ln

20

20

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Eth

no

grap

hic

stu

dy

This paper contributes to emerging ‘aerographic’ research on the socio‐materialities of air and

breath in healthcare facilities. The introduction of antibiotics changed the place of atmosphere

within hospital design. Our analysis challenges the framing of AMR as a problem of human

‘behaviour’, showing instead how the materialities of competing ‘air regimes’ come into conflict with each other, thus shaping contemporary healthcare

environments.

Building design is an overlooked avenue when seeking to address antibiotic use and the spread of

AMR.

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66

.13

10

4

Chuengsatiansup, K.

Tuberculosis in the borderlands:

migrants, microbes and more-than-

human borders Pal

grav

e C

om

mu

n

20

19

Thai

lan

d

Hu

man

Co

mm

un

ity/

pri

mar

y

care

Eth

no

grap

hic

stu

dy

Combining ethnographic materials, with national policy analysis, natural history, and microbiological

insights reveal the indeterminacy of borders and complex microbe-human entanglements.

Changes in the prevailing biocontainment model of infectious disease control are necessitated. We

propose that disease surveillance and responses need to transcend the rigid geographic notion of

space and include a more flexible topological conception of spatiality that embraces the fluidity

of pharmaceuticals, microbes, and human relations.

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19

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-4

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Dixon, J.

The ‘Drug Bag’ method: lessons

from anthropological

studies of antibiotic use in

Africa and South-East Asia

Glo

b H

ealt

h A

ctio

n

20

19

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y ca

re

Cas

e st

ud

y

The Drug Bag method produce accurate antibiotic use data as well as provide a talking point for

participants to discuss antibiotic experiences. We propose it can help improve our understanding of

antibiotic use in peoples' everyday lives across different contexts

This method adds to antibiotic use data collection in spaces beyond prescriber settings where data

are fewest and challenging to collect.

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71

6.2

01

9.

16

39

38

8

Dixon, J. Opening up

‘fever’, closing down medicines

Med

An

thro

po

l Q

20

19

Zim

bab

we

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy

This article explores the case of the Integrated Management of Childhood Illness guideline, a

periodically updated ‘global’ algorithm that shapes and normalises the centrality of medicines to care

in low- and middle-income countries and, increasingly, the imperative to ration them. This

raises the possibility that an increasingly high-tech but ‘empty’ form of pharmaceuticalised care is

being incidentally worked into the infrastructure of weak health systems

Research that aims to configure stewardship of antimicrobials in the era of concern about AMR

must attend to whether patients are categorised as targets for ‘case management’ or for ‘care’

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.6.4

.

67

Dixon, J.

Antibiotics, Rational Drug Use

and the Architecture of Global Health in

Zimbabwe

Soc

Sci M

ed

20

20

Zim

bab

we

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Eth

no

grap

hic

stu

dy In between individual and societal level ‘drivers’ of

antibiotic use is an everyday articulation of care through these substances, written-in to the scripts,

delivery chains and pedagogics of global healthcare. This article focuses on these everyday ‘architectures’ that over time and across spaces

have knitted-in antibiotics and rhetorics of control that inform current responses to AMR

We propose a reconfiguring of the architecture of global health such that frontline prescribers are able to provide ‘good’ care without necessarily turning to antibiotics. To design-out antibiotic

reliance would require attention beyond rationality, to the redrafting of blueprints that

inscribe practice.

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34

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Fortane, N.

Veterinarian ‘responsibility’:

conflicts of definition and appropriation

surrounding the public problem of

antimicrobial resistance in

France.

Pal

grav

e C

om

mu

n

20

19

Fran

ce

An

imal

Inte

nsi

ve f

arm

ing

Inte

rvie

w s

tud

y

This article explores the controversies regarding the definition and appropriation with regard to the

legitimate uses of antibiotics. Veterinarians have had to make significant compromises in order to reframe their responsibility and not lose control

over the prescription and sale of antibiotics. Previously, veterinarian responsibility was

conceived as a form of ownership where their authority to define the legitimate use of antibiotics was not contested; secondly, it was deemed to be a form of guilt whereby they were dispossessed of their legitimacy and capacity to act; thirdly, it was

framed as a form of accountability where they were able to demonstrate their role as public

health guardians

Future AMR framings could make it possible to highlight and redefine the responsibility of actors other than veterinarians alone, who remain just

one link, albeit an essential one, in the global circulation of antibiotics

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19

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73

-2

Gradmann, C.

Re-Inventing Infectious Disease:

Antibiotic Resistance and

Drug Development at

the Bayer Company 1945–

80

Med

His

t

20

16

Ger

man

y

Hu

man

Scie

nti

fic

circ

les

His

tori

cal a

nal

ysis

This paper analyses how research on antibiotic resistance has been a driving force in the

development of new antibiotics. Drug resistance, while being a problem for physicians and patients,

offers attractive perspectives for those who research and develop new medicines. It modifies pathologies in a way that opens markets for new

treatments.

Historical analysis suggest that the antibiotic discovery pipeline did not run dry. It looks more

like it was abandoned.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Gradmann, C.

From lighthouse to hothouse:

hospital hygiene, antibiotics and

the evolution of infectious

disease, 1950–1990

HP

LS

20

17

Mu

ltip

le c

ou

ntr

ies

Hu

man

Ho

spit

al

His

tori

cal a

nal

ysis

This paper traces the evolution of infectious disease following the introduction of antibiotics to

hospital medicine. It identifies three stages: the growing awareness of the hospital as a dangerous

environment in the 1950s, comprehensive attempts at improving antibiotic therapy and

hospital hygiene that followed from the 1960s and lastly the framing of such challenges as risk factors

from the 1970s

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65

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17

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76

-8

Haenssgen, M.

Tales of treatment and

new perspectives for global health

research on antimicrobial

resistance

Med

Hu

man

it

20

20

Thai

lan

d

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Cas

e st

ud

y

This case study illustrates the potential of medical humanities methods in public engagement to

foreground cultural knowledge, personal experience and ’lay’ sensemaking surrounding health systems and medicine use. Engagement

activities enabled us to formulate and test locally grounded hypotheses, gain new insights into the

social configuration of treatment seeking and reflect on the relationship between traditional healing and modern medicine in the context of

antimicrobial resistance.

Medical-humanities-informed forms of public engagement should become a standard

component of global health research, but they require extensive evaluation to assess benefits and

risks comprehensively. Global health research should be framed more actively as a learning

exercise and embed the agenda to ‘decolonise’ global health more firmly in research education

and international health policy circles.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Hinchliffe, S.

Postcolonial Global Health,

Post-Colony Microbes and Antimicrobial Resistance.

Theo

ry, C

ult

ure

& S

oci

ety

20

21

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

Theo

reti

cal c

on

trib

uti

on

Drug resistant infections emerge within and are intricate with the exercising of social and medical

power. This framing provides a means to understand and critique current methods

employed to confront the threat of widespread AMR. A global health regime that seeks to extend social and medical power, through technical and market integration, risks reproducing a form of

triumphalism and exceptionalism.

An alternative approach, based on a postcolonial as well as a ‘post-colony’ approach to health and

microbes, provides impetus to challenge the assumptions and norms of global health. It highlights the potential contribution that

vernacular approaches to human and animal health can play in altering the milieu of resistance.

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42

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81

6

06

Hinchliffe, S.

The AMR problem:

demanding economies, biological

margins, and co-producing alternative strategies

Pal

grav

e C

om

mu

n

20

18

Ban

glad

esh

An

imal

Smal

lho

lder

s

Mix

ed-m

eth

od

s In the aquatic environment and aquacultural food production, resistance drivers may relate to a

variety of processes of which antibiotic use is only one. Economic and biological drivers of disease,

farmer adaptations to disease risks and the potential paradox of pursuing pathogen-free food

production offers a means to reduce AMR risks

Instead of limiting social science to individualised or behavioural interventions, it is necessary to embed all actors from microbes to people, to

markets, within their webs of associations. The AMR problem needs to be framed as an adaptive

rather than technical challenge, and involves ownership, change and experimentation across a

range of relevant sites.By doing so, there is an opportunity to question approaches that continue anti-biosis by other means, and instead foster the different kinds of relationships that people have

with their microbial and wider environments. Rather than see microbial surplus as a weakness,

and without wanting to underplay the costs of diseases, improved food production is predicated

on these microbial relations. Disease free stock needs to be made available across the production

period at affordable prices.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Hinchliffe, S.

Production without

medicalisation: Risk practices and

disease in Bangladesh aquaculture

The

Geo

grap

h J

20

20

Ban

glad

esh

An

imal

Smal

lho

lder

s

Mix

ed-m

eth

od

s

We demonstrate the importance of socio‐economic and ecological conditions to any disease management strategy. A technical programme to introduce “disease‐free” seed faltered partly as a result of the farmers' tendency to offset disease

and livelihood risks by frequently re‐stocking their ponds. Changes to seed provision were

accompanied by calls to alter farmers' livestock production practices. Paradoxically, these changes exposed farmers to more intense risks, potentially

locking them into unsustainable disease management practices.

Technologies like improved or disease‐free seed need to be fitted to the social, economic, and

ecological conditions of production. Vernacular farming practices should be considered as key

assets rather than barriers to disease management strategies, and closer attention be paid to value chain and other risks as drivers of unsustainable practices If a key reason for treatment use is the

desperate need to make a living within an intrinsically precarious system, then finding

ecological as well as socio‐economic ways to reduce rather than intensify risk‐in‐practice is a

priority.

htt

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eoj.1

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7

1

Hobaek, B.

Less Is More: Norwegian Drug

Regulation, Antibiotic Policy, and the “Need

Clause”

Milb

ank

Q

20

19

No

rway

Hu

man

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

His

tori

cal a

nal

ysis

The Norwegian drug regulatory system focused on the rational use of drugs, tied closely to public

health needs. When antibiotic resistance became a concern, it limited the market entry of drugs considered to promote resistance, such as

combination and broad-spectrum products. This was a powerful and flexible regulatory device that

also influenced drug consumption.

This historical case demonstrates how regulatory procedures can be used to limit market entrance

and promote appropriate use simultaneously.

htt

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46

8-

00

09

.12

40

5

Kirchhelle, C.

Setting the standard:

multidisciplinary hallmarks for

structural, equitable and

tracked antibiotic policy

BM

J G

lob

Hea

lth

20

20

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Mu

ltid

isci

plin

ary

anal

ysis

Our multistage analysis revealed four central challenges facing current international antibiotic

policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we

propose three hallmarks that can support robust international antibiotic policy.

Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. To move beyond previous impasses, international policy will have to

take seriously the infrastructural dimensions of antibiotic use, provide equitable solutions for

communities across the globe and develop new forms of tracking progress that are multifactorial, integrated and empowering for the communities

employing them htt

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Kirchhelle, C.

Pharming Animals: A Global

History of Antibiotics in

Food Production (1935–2017) P

algr

ave

Co

mm

un

20

18

Mu

ltip

le c

ou

ntr

ies

An

imal

Inte

nsi

ve f

arm

ing

His

tori

cal a

nal

ysis

This article reconstructs the origins, global proliferation, and international regulation of

agricultural antibiotics. Antibiotic concerns did not develop evenly but instead gave rise to an

international patchwork of different regulatory approaches

Policymakers need to remember the long history of regulatory failures that has resulted in current

antibiotic infrastructures. For effective international stewardship to develop, it is

necessary to address the economic dependencies, deep-rooted notions of development, and

fragmented cultural understandings of risk, which all contribute to drive global antibiotic

consumption and AMR. htt

p:/

/dx.

do

i.org

/10

.10

57

/s4

15

99

-01

8-0

15

2-2

Kochhar, R.

The Virus in the Rivers: Histories and Antibiotic

Afterlives of the Bacteriophage at

the Sangam in Allahabad.

No

tes

and

Rec

ord

s: T

he

Ro

yal S

oci

ety

Jou

rnal

of

the

His

tory

of

Scie

nce

20

20

Ind

ia

Hu

man

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

Eth

no

grap

hic

stu

dy

The paper explores how the bacteriophage virus comes to be spoken about within secular and

sacred understandings of infection and riverine pollution, among contemporary historians,

biologists and doctors, and in the city's museums. At the same time, it traces the phage in histories

arcing from the ancient religious literature, to colonial disease control efforts, to today, where

bacteriophages are being conceived as a potential response to the crisis of planetary AMR.

Bacteriophages are summoned as technical quick-fixes to deal with contemporary cultural malaises. Such quick-fixes, nevertheless, remain enmeshed within wider questions of historical evidence, the

intimate connections between politics and nature, and the imagined roles for religion and technology

in dealing with crises.

htt

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oi.o

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0.1

09

8/r

snr.

20

20

.00

1

9

Podolsky, S.

Antibiotics and the social history of the controlled

clinical trial, 1950-1970.

J H

ist

Med

Alli

ed

Sci

20

10

Mu

ltip

le c

ou

ntr

ies

Hu

man

Scie

nti

fic

circ

les

His

tori

cal a

nal

ysis

This paper traces the interlinked histories of antibiotics, controlled clinical trials, and attempts

by academics to inculcate explicitly rational therapeutics among clinicians

State approval of potential medicines to treat microbial infections is relies on evidence produced

by controlled, clinical trials, a methodology developed based on evaluating antibiotics.

htt

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hm

as/j

rq0

03

39

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Agriculture,

Development and Global Health (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Podolsky, S.

History Teaches Us That

Confronting Antibiotic Resistance

Requires Stronger Global Collective

Action.

J La

w M

ed E

thic

s

20

15

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

His

tori

cal a

nal

ysis

Historical analysis highlights entrenched trends and processes, helping to frame contemporary

efforts to improve antibiotic access, conservation and innovation. For example, overuse and

underuse of antibiotics point to the structural and economic factors that impede the rational delivery

of health care. Stewardship efforts have had to confront differing notions of therapeutic

autonomy in differing states, grounded in complex relationships between doctors and their patients.

Regarding antibiotics in agriculture, would-be reformers continue to confront powerful interests

and lobbies.

Those who attempt to formulate a globally coordinated response to antibiotic resistance will

need to confront a history of heterogeneous, often uncoordinated, and at times conflicting reform efforts, whose legacies remain apparent today.

htt

ps:

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lme.

12

27

1

Podolsky, S.

The evolving response to

antibiotic resistance (1945–

2018).

Pal

grav

e C

om

mu

n

20

18

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

His

tori

cal a

nal

ysis

Concerns about AMR have depended on a series of

linked factors: the evolution and distribution of resistant microbes; our capacity and efforts to

detect such microbes; evolving models of AMR and its projected impact on medical, social, and economic futures; the linkages of antibiotic

prescribing and usage to the prevailing practice and identities of the medical and veterinary

professions, and to agribusiness practices; the projected capacity of biomedicine (and the

pharmaceutical industry) to stay ahead of AMR; the perceived global context in which AMR and the

coordination of efforts and the development of infrastructure and funding to draw attention to

and confront AMR.

Much as novel antibiotic classes and compounds are to be wished for, it would be unfortunate if their successful development led to a decline in

attention to larger structural factors. Concern over AMR has the potential to catalyze efforts to focus our attention on sanitation and the structures of

daily living, the need for global surveillance against emerging infections more generally, and the

processes underlying or preventing “rational” medical and veterinary practice.

htt

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-x

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Brown, N.

There is worse to come: the

biopolitics of traumatism in antimicrobial

resistance (AMR). So

cio

l Rev

20

17

Un

ite

d K

ingd

om

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Dis

cou

rse

/ d

ocu

me

nta

ry

anal

ysis

The AMR debate has become a significant vehicle for the expression of an ‘economic imaginary’ where microbial resistance is projected onto the ideal operations of

neoliberal markets where ‘living with’ the biotic weakens the market.

The economic imaginaries associated with AMR projects living against the biotic into the future. What if other kinds of futures are possible with a more cooperative juncture between humans

and microbes?

htt

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46

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54

X.1

24

46

Brown, N.

Economic imaginaries of the

Anti-biosis: between

‘economies of resistance’ and the

‘resistance of economies’.

Pal

grav

e C

om

mu

n

20

18

Un

ite

d K

ingd

om

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Dis

cou

rse

/ d

ocu

me

nta

ry a

nal

ysis

This paper describes the way economic principles, formulae and discourse infiltrate

biological research on AMR in two key areas. In the first, ‘economies of resistance’, the

language of market economics structures and frames microbiological explanations of bacterial

resistance. The second ‘resistance of economies’ flows in the opposite direction from

biology to economic politics: economic imaginaries of microbial life are redeployed in

large-scale debates about the nature of economic life, about the future of the welfare

state, industrial strategy, and about the politics of migration and race.

How we come to ‘know and represent’ AMR is a question of both biological and social ways of

life and living. A better awareness of the consequences of how we frame AMR in terms is needed to identify the strengths and limitations

in our political and economic responses.

htt

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41

59

9-0

18

-

01

78

-5

Buse, C.

Caring through distancing: spatial

boundaries and proximities in the

cystic fibrosis clinic. Soc

Sci M

ed

20

20

Un

ite

d K

ingd

om

Hu

man

Ho

spit

al

Eth

no

grap

hic

stu

dy

We examine how distancing can be understood as an emplaced practice of care, shaped by –

and shaping - architectures and materialities in particular contexts. We explore intersections

between care, risk, materialities and architectures

These findings have implications for the design of healthcare spaces, highlighting the potential

of materialities and architectures for constraining or enabling practices of distancing

to reduce the spread of infection

htt

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.

socs

cim

ed.2

02

0.1

13

53

1

41

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Collins, L.

Who or what has agency in the discussion of antimicrobial

resistance in UK news media (2010-

2015)? A transitivity analysis.

Hea

lth

(Lo

nd

on

)

20

18

Un

ite

d K

ingd

om

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Mix

ed-m

eth

od

s

Findings show that antibiotics and the infections they are designed to treat are instilled with

agency, that there is a tension between allocating responsibility to either doctors-as-

prescribers or patients-as-users and collectivisation of the general public as an

unspecified ‘we’: marginalising livestock farming and pharmaceutical industry responsibilities.

The response to overuse of antibiotics needs to come at multiple levels and the media might

have a role to play in promoting individual action among members of the public but there are also political and economic structures that will continue to determine who has access to

antibiotics. Social representations that empower people to engage with AMR should be

encouraged and disseminated. htt

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36

34

59

31

77

15

77

7

Davis, M.

A year in the public life of superbugs: News media on

antimicrobial resistance and

implications for health

communications.

So

c Sc

i Med

20

20

Au

stra

lia

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Dis

cou

rse

/ d

ocu

me

nta

ry

anal

ysis

AMR is a fragmented story mainly framed by scientific discovery. These stories reassure

audiences that science is seeking out the means of arresting AMR and, therefore, also constructs

lay publics as passive witnesses to the AMR story. This pattern of AMR story-telling furthers the social standing of science and scientists, but it also neglects deliberation on collective action,

important lacunae in the social response to AMR.

Finding other ways of telling the AMR story will be vital if the role of news media is to be

increased for the global effort to mitigate this challenging threat to life

htt

ps:

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0.1

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.so

cs

cim

ed.2

02

0.1

13

03

2

Giraud, E. Abundance in the

Anthropocene.

Soc

Rev

20

19

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Theo

reti

cal c

on

trib

uti

on

We present research to bed bugs, hookworms and antibiotic resistant microbes to consider how they have become intimately entangled with particular human communities as other

lifeforms have declined. We elucidate how the affordances of abundant lifeforms, including the

dangers they pose to other forms of life, are entwined with failed ‘technofixes’, colonial

legacies and contemporary inequalities.

Further ethical attention needs to be paid to finding ways of ‘being alongside’ life that is

difficult to live with, but is becoming intimately re-entangled with human worlds

htt

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03

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26

11

98

30

90

7

42

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Greenhough, B.

Unsettling antibiosis: how

might interdisciplinary

researchers generate a feeling

for the microbiome and to what effect?

Pal

grav

e C

om

mu

n

20

18

Un

ite

d K

ingd

om

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Theo

reti

cal

con

trib

uti

on

We examine how cultural, emotional and embodied responses to nonhuman others—

their ability to affect ‘us’ humans—have implications for the ways in which public health authorities, researchers and ‘lay’ publics alike

seek to engage with and govern nonhuman life.

Understanding and potentially generating different modes of relating to microbes—a

feeling for the microbiome—offers opportunities for reconfiguring how we govern

microbes and in the ways in which publics respond to perceived microbial opportunities

and threats. htt

ps:

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7/s

41

59

9-0

18

-

01

96

-3

Gröndal, H.

Harmless, friendly and lethal:

antibiotic misuse in relation to the unpredictable

bacterium Group A streptococcus.

Soci

ol H

ealt

h Il

ln

20

18

No

rway

Hu

man

Ho

spit

al &

co

mm

un

ity

/ p

rim

ary

care

Dis

cou

rse

/ d

ocu

me

nta

ry a

nal

ysis

The article examines a medical controversy concerning guidelines for managing throat

infection and antibiotic treatment. This controversy unfolds around two different ways

of relating to a specific bacterium - Group A Streptococcus. The analysis shows how two

understandings of human-microbial relations, are created and how different antibiotic

prescribing practices are justified. It provides new insights into the relations between bacteria, humans and policy in an age of

antimicrobial resistance

The definition of antibiotic misuse is unstable and policy measures aimed at reducing misuse must be related to how specific infections and

bacteria are conceptualised in the actual context the policy addresses.

htt

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1/1

46

7-

95

66

.12

74

2

Helliwell, R.

Environmental imaginaries and the

environmental sciences of

antimicrobial resistance.

Envi

ron

men

t an

d P

lan

nin

g E:

Nat

ure

an

d S

pac

e.

20

20

Un

ite

d K

ingd

om

On

e H

ealt

h

Scie

nti

fic

circ

les

Eth

no

grap

hic

stu

dy

We identify four imaginaries, the environmental hotspot, the pristine environment, the fluid

environment and the environmental reservoir. These distinct but interconnected imaginaries

produce a constellation of ideas and assumptions that shape scientific practices, the

ways and places in which the environmental dimension of AMR becomes known, and the types of interventions and actions that are

made apprehensible as a result

There needs to be greater social science involvement in efforts to understand and

address environmental aspects of AMR. Such approaches would aim to foreground the social,

economic, ecological, political and historical contingencies configuring hotspots, reservoirs,

fluidity and the pristine, and perhaps in doing so shifting these idealised spaces into new

localities.

htt

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48

48

62

09

50

75

2

43

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Irwin, R.

Imagining the postantibiotic

future: the visual culture of a global

health threat. Med

Hu

man

it

20

20

Swed

en

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Dis

cou

rse

/ d

ocu

me

nta

ry a

nal

ysis

AMR story-telling is based around the if/then structure: if we do not take certain actions

today, then we will face a postantibiotic future with certain, often catastrophic, consequences.

These stories also serve to place or deflect blame, on animals, occupations, patients,

industries and others and to highlight risks and consequences. While the convergence of a

dominant narrative indicates scientific consensus, this consensus also stifles our

collective imagination in finding new solutions to the problem.

There is need for a broader social science and humanities engagement with the visual culture

of global health AMR and antibiotic use data

htt

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edh

um

-

20

20

-01

18

84

Kamenshchikova A.

Anthropocentric framings of One

Health: an analysis of international

antimicrobial resistance policy

documents Cri

t P

ub

lic H

ealt

h

20

19

Mu

ltip

le c

ou

ntr

ies

On

e H

ealt

h

Co

mm

un

ity/

pri

mar

y

care

Dis

cou

rse

/

do

cum

enta

ry a

nal

ysis

Documents put human health at the centre, while the animal and environmental sectors are

primarily framed as a risk for human health. Although human health is, more or less

explicitly, considered to be the main problem, the animal and environmental health sectors are assigned responsibility for addressing this

problem.

The discursive space shaped by one health AMR policy documents is rather narrow and would

benefit from a broaden approach.

htt

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0/0

95

81

59

6.2

01

9.1

68

44

42

Khan, M.

LMICs as reservoirs of AMR': a

comparative analysis of policy

discourse on antimicrobial

resistance with reference to

Pakistan.

Hea

lth

Po

licy

Pla

n

20

19

Pak

ista

n

On

e H

ealt

h

Ho

spit

al &

co

mm

un

ity

/

pri

mar

y ca

re

Dis

cou

rse

/

do

cum

enta

ry a

nal

ysis

AMR was most frequently framed as a threat to human health security and economic progress,

with several documents depicting LMICs as AMR 'hotspots. there was little attention to health systems, food security or access to water and

sanitation more broadly in LMICS.

Conflicting narratives relevant to policymakers in Pakistan may affect policy-making and

impede the development and implementation of integrated initiatives needed to tackle AMR.

htt

ps:

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3

/hea

po

l/cz

z02

2

44

Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Lorimer, J.

Parasites, ghosts and mutualists: a

relational geography of

microbes for global health.

Tran

s In

stit

ute

of

Bri

tish

Geo

g

20

17

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y

care

Theo

reti

cal c

on

trib

uti

on

This paper develops a relational geography of microbes and the diseases of microbial

dysbiosis. It examines three types of human–hookworm relation: the parasite, the ghost and the mutualist reflecting on the implications for the human and nonhuman subjects of global health and the microbiopolitics of prevalent forms of antibiotic and probiotic healthcare.

The current focus in global health on deworming through vaccination and drug

delivery fails to address the socio-ecological drivers of infection intensity. The rise of the

microbiome raises some profound challenges to the geographies of global health

htt

ps:

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1/t

ran

.12

18

9

Lorimer, J.

Hookworms Make Us Human: The

Microbiome, Eco-immunology, and a

Probiotic Turn in Western Health

Care. Med

An

thro

po

l Q

20

19

Mu

ltip

le c

ou

ntr

ies

Hu

man

Co

mm

un

ity/

pri

mar

y ca

re

Theo

reti

cal

con

trib

uti

on

This article examines the political ecology of this probiotic turn in Western health care with the human increasingly recognised as a holobiont: composed of microbes and threatened by both

microbial excess and microbial absence.

Antimicrobial approaches to germ warfare are being supplemented by probiotic approaches to

restoring microbial life.

htt

ps:

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.11

11

/maq

.12

46

6

Morris, C.

Framing the agricultural use of

antibiotics and antimicrobial

resistance in UK national

newspapers and the farming press Jo

urn

al o

f R

ura

l Stu

die

s

20

16

Un

ite

d K

ingd

om

An

imal

Inte

nsi

ve f

arm

ing

Dis

cou

rse

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Four framings were identified: A ‘system failure’ frame positions intensive livestock production systems as a key contributor to AMR-related

crises in human health. A ‘maintaining the status quo’ frame argues that there is no

evidence linking antibiotics in farming to AMR in humans and stresses the necessity of (some)

antibiotic use for animal health. A third frame – which is only present in the farming media – highlights a need for voluntary, industry-led action on animal antibiotic use in terms of

farmer self-interest. Common to all frames is that the relationship between agricultural use of antibiotics and problems posed by AMR is

mostly discussed in terms of the implications for human health.

Rather than framing the question on whether or not animal antibiotic use exacerbates problems of AMR in human medicine, the ‘voluntary action’ frame turns the lens back to farm systems and their own future including the capacity to continue to rely on antibiotics to prevent and treat infections. This is still a minority position, but future research might illuminate how it develops.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses (Cont.)

Lead author Title

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logy

Description of ABU Recommendations for practice

DO

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RL

Nerlich, B.

The post-antibiotic apocalypse" and

the "war on superbugs": catastrophe discourse in

microbiology, its rhetorical form and political function.

Pu

blic

Un

der

st S

ci

20

09

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When highlighting the diminishing powers of antibiotics in the war against bacteria using the new discourse metaphor of the post-antibiotic apocalypse can be useful. It galvanizes policy makers’ and funding agencies’ attention, but

might be less well suited when trying to change ordinary people’s and ordinary policy makers’

behaviour

As with climate changes, searches for different ways of framing the issue are needed.

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/09

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Sarioloa, S.

Toward a Symbiotic Perspective on Public Health:

Recognizing the Ambivalence of Microbes in the Anthropocene.

Mic

roo

rgan

ism

s

20

20

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Antibiotics have altered microbial development by providing stringent natural selection on

bacterial species. We propose a perspective on public health that recognizes microbial

evolution through symbiotic associations and through lateral gene transfer. This perspective

includes both the pathogenic and beneficial interactions of humans with bacteria, as well as

combining the outlook of the "One Health" model with the genomic methodologies

In the Anthropocene, the conditions for microbial evolution have been altered by human interventions, and public health

initiatives must recognize both the beneficial interactions of microbes with their hosts as well

as their pathogenic interactions.

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Walker, I.

Beyond the military metaphor. Comparing

antimicrobial resistance and the

COVID-19 pandemic in the United Kingdom.

Med

An

th T

heo

ry

20

20

Un

ite

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ingd

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Military metaphors shape the limits and

possibilities for conceptualising and responding to complex challenges of contagion. I draw from

criticisms of the use of military metaphor in scientific and policy descriptions of

antimicrobial resistance (AMR) to compare with and explore the use of military metaphors in

descriptions of the COVID-19 pandemic. As AMR research has recognised the importance of

symbiotic human–microbe relationships and new areas of interdisciplinary collaboration in

recent years, a corresponding decline in the use of military metaphor in scientific discourse has

begun to emerge

Diversity of language and imaginative framings is necessary, just as diversity of expertise is

required for complex global health challenges such as AMR.

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Appendix: Summary of the published, peer-reviewed social science studies investigating antibiotic use referred to in the preparation of the report – NETWORKS – Discourses (Cont.)

Lead author Title

Jou

rnal

Ye

ar

Co

un

trie

s

Po

pu

lati

on

Sett

ing

Me

tho

do

logy

Description of ABU Recommendations for practice

DO

I/U

RL

Wernli, D.

Mapping global policy discourse on

antimicrobial resistance.

BM

J G

lob

Hea

lth

20

17

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On

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Providing a better understanding of the competing discourses that prevail regarding

AMR can support those seeking to draw attention on the problem to tailor their

message to different constituencies We identify 'AMR as healthcare', 'AMR as development', 'AMR as innovation' and 'AMR as security' as

frequent frames used in dealing with AMR. We found that 'AMR as One Health' constitutes a

recent framing of the topic. Each frame originates in distinct scientific fields,

conceptualises the main causes of AMR and prioritises different interventions and

measurements

Better understanding and integration of AMR policy frames into an overarching social and

ecological framework can help identify the main tensions and synergies between priorities and

support policy progress in tackling AMR.

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